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STATE OF CALIFORNIA w « co STATE WATER RESOURCES CONTROL BOARD Yom, v o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A nio COMPLETE THIS FORM FOR EACHFACILITY/SITE MARK ONLY J NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANE Y CLOSED SITE j ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE D I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BEC PLETED) 08A OR FACILITY NAME ! NAME OF OPERATOR F PrL 5 ADDRESS NEAREST CROSS STREET PARCEL If(OPTIONAL) bb w CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE CAv BOX TOINDICATE Q CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY Q STATE-AGENCY Q FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTORQ I/ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) RESERVATION Q 3 FARM Q 4 PROCESSOR Q 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE 11. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box ID Indicate Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY Q CORPORATION [] PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY GIN NAME STATE ZIP CODE PHONE#WITH AREA CODE _7 111. TANK OWNER INFORMATION•(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓box to indicate Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY CITY NAME [STATE ZIP CODE =ITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if q estionns an.e. TY(TK) HQ F4747 eW1 V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED ✓box Io indicate Q 1 SELF-INSURED Q 2 GUARANTEE Q 3 INSURANCE Q 4 SURETY BOND Q 5 LETTER OF CREDIT Q 6 EXEMPTION Q 99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ II.❑ III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME(PRINTED 8 SIGNATURE) APPLICANTS TITLE DATE MOINTWDAYNEAR LOCAL AGENCY USE ONLY �tl COUNTY# JURISDICTION# FACILITY# I" 5'A',*-',/ F F0E LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPvdSOR•DIS RICT CODE -OPTIONAL 2 66 ✓! THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION, FOAM B,UNLESS THIS IS A CHANGE OF SITE INFORMATlnFOM3A-5 . FORM A(5-91)